HESI Review Questions Combined pt. 4

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are temperature of 96 degrees Fahrenheit, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure 64 mmHg, and central venous pressure 7 mmHg. Serum laboratory findings include hemoglobin 6.6 grams/dl, platelets 60,000/mm^3, and white blood cell count 30,000mm^3. Based on these findings the client is that greatest risk for which pathophysiological condition? A. Chronic obstructive pulmonary disease (COPD) B. Multiple organ dysfunction syndrome (MODS) C. Disseminated intravascular coagulation (DIC) D. Acquired immune deficiency syndrome (AIDS)

B. Multiple organ dysfunction syndrome (MODS)

A young adult female client with recurrent pelvic pain for 3 years returns to the clinic for relief of severe dysmenorrhea. The nurse views her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client? A. An option to diagnose disease extent and provide therapeutic treatment is laparoscopy B. Infertility is successfully treated with removal of intra-abdominal endometrial lesions C. The symptoms of endometriosis can increase with menopause D. Oral contraceptives increase the symptoms of endometriosis

D. Oral contraceptives increase the symptoms of endometriosis

Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl. The nurse prepares to administer a unit of blood for an emergency transfusion. That client has an AB negative blood type and the blood bank sends a unit of Type A RH negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement? A. Recheck the clients hemoglobin, blood type, and RH factor B. Administer normal saline until Type AB negative is available C. Obtain additional consent for administration of Type A negative blood D. Transfuse Type A negative blood until Type AB negative is available

D. Transfuse Type A negative blood until Type AB negative is available

The healthcare provider prescribes a sedative for a client with severe hypothyroidism. The nurse plans to contact the provider to review the safety of the prescription for the client and consultS first with the charge nurse. The charge nurse notes that the prescription is written legally and completely. How should the charge nurse respond? a. Affirm the nurses plan to review the prescription with the provider b. Advise the nurse to administer the medication as prescribed c. Assume responsibility for discussing the concern with the provider d. Offer to administer the prescription since the nurse has concerns

a. Affirm the nurses plan to review the prescription with the provider

After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care? a. Apply sequential compression stockings b. Monitor for urinary incontinence c. Observe for signs of depression d. Provide a wide variety of meal choices

a. Apply sequential compression stockings

A male client who arrives at the emergency department after a motor vehicle collision (MVC) tells the nurse "The car started to slide, and I just decided to let it go. Everyone would be better off if I was no longer was around." How should the nurse respond? a. Ask the client if the MVC was a suicide attempt b. Assess the client for other symptoms of depression c. Report to the health care provider that the client may need an antidepressant d. Determine what is going on in the clients life to make him feel depressed

a. Ask the client if the MVC was a suicide attempt

The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse do first? a. Change the surgical dressing to observe the appearance of the incision b. Assess the level of consciousness and vital signs for both clients c. Review the plan of care and the medications that are due for both clients d. Complete a head-to-toe assessment of the client with pneumonia

a. Change the surgical dressing to observe the appearance of the incision

The nurse notes that a postoperative adult client's respiratory rate is 10 breaths/minute. Which factor is the most likely explanation for this finding? a. The client's PCA pump with morphine sulfate was discontinued 15 minutes ago b. The client's hemoglobin is 10.1 gm/dl and hematocrit is 30.4% c. The client has a 20-pack year history of smoking cigarettes d. The client has a history of allergic bronchitis with recurrent bacterial pneumonia

a. The client's PCA pump with morphine sulfate was discontinued 15 minutes ago

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is a rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? a. Demonstrate how to help the client move more efficiently b. Affirm that the client should arise slowly from the chair c. Offer a PRN analgesic to reduce painful movement d. Tell the UAP to assist the client in moving more quickly

b. Affirm that the client should arise slowly from the chair

The nurse is caring for four clients on a medical unit. Which client is at an increased risk for candidiasis? a. An adolescent in the third trimester of pregnancy who has persistent hyperemesis b. An adult with acquired immunodeficiency syndrome who is taking antibiotics c. The client who is admitted for preoperative surgical consult for morbid obesity d. An older client with chronic kidney disease who has uremic frost

b. An adult with acquired immunodeficiency syndrome who is taking antibiotics

In planning care for a client with early-stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury due to impaired judgement. Which intervention is most important for the nurse to include in this clients plan of care? a. Offer the client frequent reassurance that he/she will be safe b. Arrange the client's environment so the client can move about freely c. Engage the client in regularly scheduled activities during the day d. Assign a UAP to provide the client with total personal care

b. Arrange the client's environment so the client can move about freely

The mother of a child recently diagnosed with asthma ask the nurse how to help protect her child from having asthma attacks. To avoid triggers for asthma attacks, which instruction should the nurse provide the mother? Select all that apply. a. Decrease the raw sugars in the diet b. Close car windows and use air conditioner c. Avoid sudden changes in temperature d. Stay indoors when grass is being cut e. Keep away from pets with long hair

b. Close car windows and use air conditioner c. Avoid sudden changes in temperature d. Stay indoors when grass is being cut e. Keep away from pets with long hair

Which assessment is most important for the nurse to include in the daily plan of care for a client with a burnt extremity? a. Extremity sensation b. Distal pulse intensity c. Presence of exudate d. Range of motion

b. Distal pulse intensity

An older client is referred to a rehabilitation facility following a cerebrovascular accident. The client is aphasic with left sided paralysis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care? a. Initiate passive range of motion exercises b. Facilitate a consultation for speech therapy c. Use pictures and gestures to communicate d. Arrange for daily home care assistance

b. Facilitate a consultation for speech therapy

A client is admitted to the labor and delivery unit in early labor and the nurses assesses the status of her contractions. The frequency of contractions is most accurately valued by counting the minutes and seconds in which manner? a. From the peak of one contraction to the peak of the next contraction b. From the beginning of one contraction to the beginning of the next contraction c. From the beginning of one contraction to the end of that contraction d. From the end of one contraction to the beginning of the next contraction

b. From the beginning of one contraction to the beginning of the next contraction

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first? a. Insert a nasogastric tube for feeding b. Initiated a prescribed IV for parenteral fluid c. Give the infant 5% dextrose in water orally d. Feed the infant 3 ounces of isomil

b. Initiated a prescribed IV for parenteral fluid

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document the sound? a. Pericardial friction rub b. Murmur c. S1 S2 S3 d. S1 S2

b. Murmur

The parents bring their one-year-old child with a ventricular septal defect to the clinic for a well child visit. Which assessment finding should the nurse report to the health care provider immediately? a. Respirations of 26 breaths/minute at rest b. Expected weight and growth care for an infant c. 2+ pitting edema in the extremities d. Heart rate of 105 beats/minute

c. 2+ pitting edema in the extremities

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? a. In adult one day postoperative laparoscopic cholecystectomy requesting pain medication b. An adult who's in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours c. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection d. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery

c. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection

What action should the nurse take first when a client is inadvertently given an incorrect dose of a medication? a. Notify the health care provider b. Complete an incident report documenting the facts c. Assess the client for any adverse effects d. Document the events leading to the error in the nurses' notes

c. Assess the client for any adverse effects

A young client involved in a motorcycle collision experienced a laceration of the gastrocnemius muscle. Which instruction should the nurse provide to the practical nurse who is caring for this client? a. Avoid washing the limb when assisting with bathing b. Elevate limb above the heart when lying in bed c. Avoid planter flexion of the affected limb d. Perform range of motion on the affected limb

c. Avoid planter flexion of the affected limb

The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, locks the door and vomits. Which physical assessment should the nurse implement if bulimia is suspected? a. Skin of palms of the hand b. Current height and weight c. Condition of tooth enamel d. Length of last menses

c. Condition of tooth enamel

A client with chronic obstructive lung disease was receiving oxygen at 1.5 liters/minute by nasal cannula, is currently short of breath. What action should the nurse take first? a. Have the client breathe into a paper bag b. Increase oxygen to three liters/minute c. Instruct the client to purse lip breathe d. Ask the client to take short, rapid breaths

c. Instruct the client to purse lip breathe

A client with chronic renal insufficiency is preparing for discharge from the hospital. Which information is most important for the nurse to include in this client discharge teaching? a. Use of topical applications to manage pruritis b. Strategies to promote independent self-care c. Instructions regarding a restricted protein diet d. Need for maintaining good oral hygiene

c. Instructions regarding a restricted protein diet

What is the priority nursing problem for a client with hypoparathyroidism?a. Anxiety b. Imbalanced nutrition c. Risk for injury d. Deficient knowledge

c. Risk for injury

A client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol use. What should the nurse administer to prevent the development of Wernicke's syndrome? a. Atenolol b. Lorazepam c. Thiamine d. Famotidine

c. Thiamine

Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? a. Discontinue all non-steroidal anti-inflammatory medications b. Avoid using heat or ice to injured muscles while taking this medication c. Use cold and allergy medications only as directed by a health care provider d. Take this medication on an empty stomach

c. Use cold and allergy medications only as directed by a health care provider

The nurse learns in report that a client was unstable during the previous shift. The nurse should plan to carefully monitor which parameter? a. Circadian rhythms b. Basal metabolic rate c. Vital signs d. Stress levels

c. Vital signs

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider? a. Nausea and headache b. Yellow tinged sputum c. Watery diarrhea d. Increased fatigue

c. Watery diarrhea

A 300 ml unit of packed red blood cells is prescribed for a client with heart failure who has 3+ pitting adima, shortness of breath with any activity, and crackles in both lung bases. What rate should the nurse administer the blood? a. 50 ml/hour b. 150 ml/hour c. 300 ml/hour d. 75 ml/hour

d. 75 ml/hour

Which environmental factors most significant when planning care for a client with ostemalacia? a. Quiet, calm surrounding b. Cool, moist air c. Stimulating sounds and activity d. Adequate sunlight

d. Adequate sunlight

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? a. Prevention through nutrition and exercise b. Avoidance of foods containing purine c. Immobilization of affected joints d. Application of heat and cold therapy

d. Application of heat and cold therapy

A woman at 12 weeks' gestation comes into the clinic for her first prenatal visit. After completing health history, the nurse should discuss which topic about pregnancy at this initial visit? a. Concerns about parenting b. Knowledge about labor and delivery c. Complications associated with childbirth d. Cultural practices related to childbearing

d. Cultural practices related to childbearing

A woman with an anxiety disorder calls her obstetricians office and tells the nurse of increasing anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her anti-anxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? a. Describe the transmission of drugs to the infant through breast milk b. Encourage her to use stress relieving alternatives, such as deep breathing exercises c. Explain that anxiety is a normal response for a mother of a three-week old d. Inform her that some anti-anxiety medications are safe to take while breastfeeding

d. Inform her that some anti-anxiety medications are safe to take while breastfeeding

The mother of a 7-month-old brings the infant to clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. Tell the mother to cleanse with soap and water at each diaper change b. Encourage the mother to apply lotion with each diaper change c. Ask the mother to decrease the infants intake of fruits for 24 hours d. Instruct the mother to change the child's diaper more often

d. Instruct the mother to change the child's diaper more often

A client with a swollen right toe receives a prescription for colchicine to treat their present symptoms of gout and a prescription for allopurinol to control future attacks. What information is most important for the nurse to teach the client? a. Watch for thin hair b. Expect anorexia c. Anticipate fever d. Report diarrhea

d. Report diarrhea